Boston Life Claim Form Details

In order to file a Boston Mutual Claim Bd 1321 0706 Form, you will need to gather some important information. The first step is to make sure that you have the correct form. You can find the form on the Boston Mutual website, or you can contact their customer service department for a copy. Once you have the form, you will need to fill it out completely and accurately. Be sure to include all of your contact information, as well as the details of your claim. Submit the form and supporting documentation to Boston Mutual, and they will take care of the rest.

If you wish to first find out how much time you will need to fill in the boston mutual claim bd 1321 0706 form and how many pages it has, here is some general information that will be of use.

QuestionAnswer
Form NameBoston Mutual Claim Bd 1321 0706 Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesutual savings form, boston mutual claim, boston mutual life insurance log in, boston mutual life insurance company claims

Form Preview Example

Boston Mutual Life Insurance Company

Group Disability

Claim Filing Instructions

IMPORTANT: All portions of this claim form must be completed after disability begins to avoid undue delay in processing claimant’s request for benefits. If you have any questions when completing this form, please call our:

Toll Free Number - (800) 320-4445

1.Complete "Employee - Initial Disability Benefits Claim Form" in full.

2.Have treating physician complete the "Physician - Initial Disability Claim Form" and return to you.

3.Have Employer complete the "Employer - Initial Claim Form" and return to you.

4.Submit all completed forms to the address below or you may fax all completed forms to our:

Toll Free Fax Number - (888) 594-5729.

Mail To:

Boston Mutual Life Insurance Company

Benefits Administration

P.O. Box 268956

Oklahoma City, OK 73126-8956

BD-1321-0706

Mail to: Boston Mutual Life Insurance Company

Benefits Administration

P.O. Box 268956

Oklahoma City, OK 73126-8956

Toll Free Phone # 1-800-320-4445

Toll Free Fax # 1-888-594-5729

EMPLOYER – INITIAL CLAIM FORM

Employee Name:

Occupation:

Social Security Number:

Hire Date:

STATUS OF EMPLOYMENT: Full Time:

Part Time:

Days per week: ________ Hours per day: _________

 

If employee’s status has changed, please check the appropriate box and provide change date below:

 

 

 

 

Lay Off:

 

Leave of Absence:

 

 

 

 

Terminated:

Retired:

 

PREMIUMS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are the employee’s disability premium contributions deducted pre-tax or post-tax ?

 

 

 

 

 

What percentage of the disability premiums do you pay?_________%

 

 

 

 

 

Are Social Security taxes withheld from employee’s pay check? Yes No

 

 

 

 

 

Date that last disability premiums deducted from payroll:___________ Amount deducted: $__________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SALARY AT TIME OF DISABILITY:

 

 

 

 

 

 

 

 

 

 

 

Hourly: $_________

Weekly: $__________ Monthly: $__________

 

 

 

 

 

Annually: $__________________

$_____________________

 

 

 

 

 

 

W-2, previous calendar year

Year-to-date, current calendar year

 

 

 

 

 

Date last worked?______________________

 

 

 

 

 

 

 

 

 

 

 

Has employee returned to work? Yes No Return date: ________________ Full Time Part Time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is the employee receiving or eligible to receive any of the following?

 

 

Dates Benefits

 

 

Yes

No

Amount

 

Wk

Mo

 

Company Name and Phone Number

 

Begin

End

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Group

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Disability

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Salary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Continuation

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sick Leave

 

$

 

 

 

 

 

 

 

 

 

PTO/PPT

 

$

 

 

 

 

 

 

 

 

 

Other (Bonus, etc.)

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Retirement/Pension

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is disability the result of work related injury/illness? Yes No

 

 

 

 

 

 

 

If yes, has a Workers' Compensation claim been filed? Yes No

 

 

 

 

 

Please provide name and phone number of Workers' Compensation carrier:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Name:

 

 

 

 

 

 

 

 

 

Office Phone Number:

Fax Phone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address:

 

 

 

 

 

 

 

 

 

City:

State:

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form completed by: (please print)

 

 

 

 

 

 

 

Title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature:

 

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

This documents that the above statements are true and complete to the best of my knowledge.

 

BD-1321-0706

Mail to: Boston Mutual Life Insurance Company

Benefits Administration

P.O. Box 268956

Oklahoma City, OK 73126-8956

Toll Free Phone # 1-800-320-4445

Toll Free Fax # 1-888-594-5729

EMPLOYEE - INITIAL DISABILITY CLAIM FORM

WARNING: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim containing any false, incomplete, or misleading information may be guilty of insurance fraud and subject to criminal and civil penalties.

Name:

Social Security Number:

Date of Birth:

Complete Mailing Address:

Complete Resident Address:

Telephone Number:

Do you have dependents under age 18? Yes No If yes, please list dependent names and birth dates below:

1)Please list medical condition or injury causing disability:

2)If disability is the result of an accident, please explain where, when, and how accident happened:

3)Is your disability the result of your employment? Yes No If yes, please submit copy of Workers' Compensation award or denial letter.

4)Please list all dates of medical treatment pertaining to current disability:

5)Have you ever had or been treated for same or

similar condition? Yes No If yes, please explain:

6)Please list name and phone number of treating physician(s):

7)Date Last Worked:

Date Returned to Work:

8)If you have not returned to work, what is the anticipated return date?

Full Time: ______________________

Part Time:______________________

9)If your request for benefits is approved, do you want Federal Taxes withheld from each benefit check? Yes No

If yes, please indicate dollar amount below:

(Minimum amount required is $87 per month.) $_______________

10) Please identify other income sources and amounts of income which you are receiving or may be entitled to receive during this disability:

Social Security - Disability Retirement

Yes

No

$__________

V.A. Benefits

Yes

No

$___________

Dependent Social Security

Yes

No

$__________

Sick Leave or Wage Continuation

Yes

No

$___________

State Disability

Yes

No

$__________

Retirement (normal, early, or disability)

Yes

No

$___________

Other Group Disability Coverage

Yes

No

$__________

 

 

 

 

Include a copy of your award or denial letter from any source that you have received.

AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION

I hereby authorize the entities specified below to disclose any information about my entire medical record and history of treatment for physical and/or emotional illness

to include psychological testing, except psychotherapy notes, to individuals representing Boston Mutual Life Insurance Company (BMLIC) who are involved in determining whether I am eligible for benefits under my insurance coverage. Those so authorized are: a) licensed physicians or medical practitioners; b) hospitals, clinics or medically-related facilities; c) health plans; d) Veteran’s Administration; e) past or present employers; f) pharmacy; g) insurance companies; h) Social Security Administration; i) retirement systems; j) Department of Motor Vehicles, and k) Workers’ Compensation carrier.

NOTICE: Information authorized for release may include information on communicable or venereal diseases such as hepatitis, syphilis, gonorrhea, Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) or other conditions for which you may have been treated. This authorization excludes disclosure of the result of a test for HIV if you have tested HIV positive but have not developed symptoms of the disease AIDS. Such test results shall not be discovered or published. Nothing in the caveat will prohibit this authorization from including the fact that you have AIDS.

I understand that I may refuse to sign this authorization; however, if I do not sign the authorization, my failure to sign the authorization may result in a denial of benefits. I understand that I may revoke this authorization at any time by writing to Boston Mutual Life Insurance Company, Benefits Administration, P.O. Box 268956, Oklahoma City, Oklahoma 73126-8956 or calling toll free 1-800-320-4445. I understand that my right to revoke this authorization is limited to the extent that BMLIC has taken action in reliance on the authorization; or, the law provides BMLIC with the right to contest my insurance coverage or a claim under my insurance coverage. A copy of this authorization will be as valid as the original. I understand that if protected health information is disclosed to a person or organization that is not required to comply with federal privacy regulations, the information may be re-disclosed and no longer protected by federal privacy regulations.

For health insurance coverage, this authorization will expire twenty-four months from the date it is signed or upon termination of my insurance policy, whichever occurs first. For insurance coverage other than health insurance, this authorization will expire twenty-four months from the date it is signed or upon expiration of my claim for benefits, whichever occurs first. For Arizona residents, release of HIV/AIDS released information can only be disclosed for a period not to exceed 180 days from the date shown below.

Signature :____________________________________________ Print Insured’s/Patient Name: ______________________________________ Date:_______________

Please retain a copy for your personal records, or you may request a copy from our company.

BD-1321-0706

FAILURE TO SIGN & DATE FORM WILL DELAY BENEFITS

Mail to: Boston Mutual Life Insurance Company

Benefits Administration

P.O. Box 268956

Oklahoma City, OK 73126-8956

Toll Free Phone # 1-800-320-4445

Toll Free Fax # 1-888-594-5729

PHYSICIAN - INITIAL DISABILITY CLAIM FORM

Patient’s Name:

Social Security Number:

Date of Birth:

 

Diagnosis: Please list diagnosis resulting in patient’s temporary total disability (including complications)

 

 

Diagnosis: ________________________________________________________________

ICD9 Code: __________________________________

 

 

Diagnosis: ________________________________________________________________

ICD9 Code: __________________________________

 

 

 

 

 

 

 

 

Is disability the direct result of patient’s employment?

Yes No

 

 

 

 

 

 

 

 

 

 

Is disability the result of a pregnancy? Yes

No

If yes, date pregnancy was diagnosed:

 

 

 

 

 

 

 

 

 

Delivery date: (if delivered)

 

Expected delivery date: (if not delivered)

 

 

History: Was the patient referred to you?

Yes No Unknown If yes, please provide name and phone number of referring physician:

 

 

 

 

 

 

 

Date symptoms first appeared or accident happened?

 

Date patient first consulted you for this condition?

 

 

 

 

 

 

 

 

Are you aware if this patient has ever had the same or similar condition? Yes No If yes, please provide explanation including first date of onset.

Treatment: Is patient still under your care? Yes No If yes, date of next appointment: _____________________________________________

List all treatment dates:______________________________________________________________________________________________________

Please describe treatment plan: _______________________________________________________________________________________________

If patient is no longer under your care, please provide name and phone number of current physician:

Unknown

 

 

 

Has patient been confined to a hospital? Yes No

Admitted: ___________________________

Discharged: _____________________________

Hospital Name:

Phone Number:

 

 

 

 

If surgery is/was necessary, please list procedure(s):

 

 

 

 

 

Date scheduled:

Date performed:

 

Prognosis: Please list date(s) of temporary total disability (unable to work) From: ________________ Through: __________________

If patient is currently totally disabled, please indicate the anticipated length of disability by checking the appropriate box below:

Months:

or Permanently Disabled or Other

________________________

1

2

3

4

5

6

7

8

9

10

11

12

 

 

Impairment: List functional limitations/restrictions that render your patient temporarily totally disabled:

 

 

 

 

 

 

 

 

 

 

Attending Physician’s Name: (please print)

 

 

 

 

Degree:

 

Specialty:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address:

 

 

 

 

 

 

 

 

 

 

City:

 

State/Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

Office Phone Number:

 

 

 

 

 

 

 

 

Fax Phone Number:

 

Federal Tax ID Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form completed by:

Title:

Signature of Physician:

Date:

 

 

Attention Physician: This form documents your verification that the above named individual is totally disabled from their occupation. You will be asked periodically for updates related to the individual’s disability and treatment plan.

BD-1321-0706

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